title: Effective in-service training design and delivery: evidence from an integrative literature review.
abstract: BACKGROUND
  In-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.
  
  
  METHODS
  A literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.
  
  
  RESULTS
  The evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.
  
  
  CONCLUSIONS
  Educational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.
authors.affiliation: Jhpiego Corporation, 1615 Thames Street, Baltimore, MD 21231, USA. julia.bluestone@jhpiego.org.
authors.forename: Julia
authors.initials: J
authors.lastname: Bluestone
authors.forename: Peter
authors.initials: P
authors.lastname: Johnson
authors.forename: Judith
authors.initials: J
authors.lastname: Fullerton
authors.forename: Catherine
authors.initials: C
authors.lastname: Carr
authors.forename: Jessica
authors.initials: J
authors.lastname: Alderman
authors.forename: James
authors.initials: J
authors.lastname: BonTempo
mesh_terms: D002983:Clinical Competence; D003198:Computer Simulation; D004502:Education, Medical, Continuing / Q000379:methods* / Q000592:standards; D006282:Health Personnel / Q000193:education*; D006801:Humans; D007318:Inservice Training / Q000379:methods* / Q000458:organization & administration; D016544:Patient Simulation; D013663:Teaching / Q000379:methods